OSTOMY, CONTINENCE & SKIN CARE

The topics ostomy and continence have been combined in this stream. The literature about them is quite separate, but the common thread is protection and management of the skin. Therefore, in searching the literature and making recommendations, skin care is the focus.

Injury may be caused by excreted bodily fluids due to fecal or urinary incontinence or to stoma complications. Stoma complications have been classified into five categories according to etiology or location: poor sitting, stoma proper, peri-intestinal area, mucocutaneous junction, and iatrogenic. In addition to chemical injury, stoma complications may result in mechanical injury, infection, and disease-related lesions. Patients with incontinence or an ostomy and the associated potential complications can expect a significant impact on their quality of life.

A systematic literature search for clinical practice guidelines on ostomy continence and skincare was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

Fifty-one (51) ostomy continence skin care clinical practice guidelines were found in the English literature from 2002 until May 2007. 43 (84%) of these published articles were excluded because they were: studies (8), irrelevant (20), case series (2), narrative reviews or systematic reviews (4), education pieces (5), unable to locate (3), conference program (1),

Of the identified papers, eight (8) guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, the rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead, the guidelines that received the highest scores for most of the domains and particularly for the rigour of development were ranked highest and their recommendations will be reported throughout this ostomy continence skincare stream.

The most highly ranked guidelines were two versions of the Registered Nurses Association of Ontario (RNAO) on promoting continence (2002 and 2005); one by the National Institute for Clinical Excellence (NICE) on the management of incontinence in women (2006) and a summary version; one by the Scottish Intercollegiate Guidelines Network on the management of urinary incontinence in primary care (2004); one by Dowling-Castronovo and Bradway on urinary incontinence; one by the Singapore Ministry of Health on the management of urinary incontinence (2003); and one by Braathen et al on photodynamic therapy for non-melanoma skin cancer (2007). Figure I illustrates the domain scores for these guidelines.

The focus of the recommendations from the guidelines is the management of skin when there is excess moisture due to incontinence. Since no guidelines were found about the management of ostomies, recommendations about ostomies are not in this overview. Recommendations in relation to ostomy are based on individual studies and expert knowledge and are found under specific topics within the stream.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history from the person identified to have urinary incontinence	5
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life	5
3	Provide information and advice on treatment options available in both primary and secondary care	5
4	Use a validated quality of life and incontinence severity questionnaire, e.g., ICIQ, BFLUTS, I-QOL, SUIQQ, UISS, SEAPI-QMM, ISI and KHQ.	2
Provide Local Care		Level of Evidence
5	Recommend containment products and reassess their suitability	5
6	Consider absorbent products as:- a coping strategy pending definitive treatment- an adjunct to other ongoing therapy- long term management of urinary incontinence only after other treatment options have been explored	5
7	Inspect genital-perineal area daily to identify signs of contact dermatitis and skin excoriation.	5
8	Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	5
Provide Organizational Support		Level of Evidence
9	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information	5

High Ranking Guidelines
1	Management of urinary incontinence in women	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Urinary incontinence the management of urinary incontinence in women. National Collaborating Centre for Women’s and Children’s Health. National Institute for Health and Clinical Excellence. October 2006.
This is a well-developed comprehensive guideline that provides information about skincare in relation to urinary incontinence. There is a summary version of this guideline (36 pages instead of 249) that may be considered a quick reference guide. The latter does not contain details of the supporting documentation for recommendations.
2	Continence	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Nursing Best Practice Guideline: Promoting Continence Using Prompted Voiding. Registered Nursing Association of Ontario. March 2005.
This is a very well-developed clinical practice guideline that provides clear and succinct recommendations for clinical practice and indicates their supporting evidence. Although this guideline was developed for nurses, its recommendations would be useful to clinicians from other disciplines, e.g., family physicians, physical and occupational therapists, dietitians. It is the updated version of the 2002 RNAO guideline below.
3	Continence	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Nursing Best Practice Guideline: Promoting Continence Using Prompted Voiding. Registered Nursing Association of Ontario. January 2002.
This very well-developed earlier version of the RNAO guideline is included because, on appraisal, it received higher scores for some domains than the more recent version. This guideline will be of interest to clinicians who want to review in detail.
4	Urinary incontinence	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Management of urinary incontinence in primary care A national clinical guideline. Scottish Intercollegiate Guidelines Network. December 2004. Updated September 2005. http://www.sign.ac.uk/pdf/sign79.pdf
This guideline presents information about skincare. There is a quick reference guide that summarizes the main recommendations, located at the following website: http://www.sign.ac.uk/pdf/qrg79.pdf
5	Urinary incontinence	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Dowling-Castronovo A, Bradway C. Urinary incontinence. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 83-98. [26 references].
The National Guideline Clearinghouse version (9 pages) of this guideline was reviewed for WoundPedia. It provides short concise recommendations on evaluation and treatment or management of urinary incontinence.
6	Nursing management of urinary incontinence	Quality Indicator	Type: CPG (Clinical Practice Guideline)
Singapore Ministry of Health. Nursing management of patients with urinary incontinence. Singapore: Singapore Ministry of Health; 2003 Dec. 40 p. [32 references].
The National Guideline Clearinghouse version (17 pages) of this guideline was reviewed for WoundPedia. It provides a short concise overview of recommendations on this topic.

Age alters skin integrity. The epidermis, dermis and subcutaneous layers gradually thin, and elastin, collagen, and subcutaneous fat decrease. These changes make the skin more susceptible to mechanical trauma, moisture loss, and infection. Physiologic functions, such as injury response, healing, thermoregulation, barrier function, immune function, sensory perception, and vascular responsiveness are also affected. Among elderly patients, environmental and physical factors can affect skin integrity, especially if the skin is dry, frail, or overhydrated, or if the individual’s health is compromised.

Significant exposure to ultraviolet light, due to many years of sun exposure, causes numerous skin changes:

• Premature ageing of the skin
• Thinning of the skin with fine wrinkles and skin tears
• Blood vessel changes resulting in easy bruising, especially on the arms, and
• Telangiectasia become more prominent, especially on the face
• Skin pigment changes, including solar lentigos
• Pigmented nevi, commonly called moles
• Precancerous red, scaly lesions, especially on the face, ears and the back of the hands (actinic keratoses), or on the lip (actinic cheilitis).

Exposure to therapeutic radiation produces localized skin damage. The effects of radiation therapy depend on the area and tissue volume treated, the type of radiation and the schedule, the total dose administered, individual skin characteristics, age, health status, and comorbid conditions. Skin folds, the skin over bony prominences, facial skin, and surgical wounds tend to be more sensitive.

Effects of radiation may be seen during treatment or may not occur until months or years later. The earliest change is usually erythema, which may occur after a few weeks of treatment, followed by pruritus and moist or dry desquamation. Moisturizing lotion may be useful for pruritus associated with dry desquamation. Zinc oxide, hydrocolloid, or wet astringent dressings may help to manage moist desquamation. These areas usually heal within a few weeks of completion of radiotherapy. Irradiated areas may remain more sensitive to temperature, more susceptible to sunburn, and dryer than non-irradiated skin. Delayed radiation effects include skin atrophy; altered pigmentation; loss of hair, sweat glands and sebaceous glands; increased fragility and decreased capacity for repair; ulceration and necrosis; lymphedema due to lymphatic fibrosis; and increased risk of non-melanoma skin cancer.

Maintenance of skin integrity in individuals with fragile and/or damaged skin relies on avoidance of adhesives, harsh soaps, perfumes, powders, and deodorants; prevention of trauma from friction, such as rubbing the skin dry, shaving, and wearing tight clothing; protection from temperature changes and sun exposure; and maintenance of appropriate levels of hydration.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess patients with skin changes due to ageing, ultraviolet exposure or therapeutic radiation for risk of loss of skin integrity and/or barrier function.	Not Assessed
2	Monitor precancerous skin changes regularly to allow early diagnosis and treatment of skin cancer.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
3	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
4	Develop and implement an individualized treatment plan in patients with skin trauma, infection or radiation effects to promote healing.	Not Assessed
5	Develop and implement an individualized care plan to maintain skin integrity in patients with compromised skin.	Not Assessed
Provide Organizational Support		Level of Evidence
6	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Skin Integrity	Quality Indicator	Type: Narrative Review
Sibbald RG, Campbell K, Coutts P, Queen D. Intact Skin – An Integrity not to be lost. Ostomy Wound Continence 2003;49(6):27-41
This comprehensive article outlines skin integrity issues and suggests products that might be used for prevention and treatment.
2	Photo-Aging	Quality Indicator	Type: Case-control study (2 groups)
Lee JH, Roh MR, Lee KH. Effects of infrared radiation on skin photo-ageing and pigmentation. Yonsei Med J. 2006 Aug 31;47(4):485-90.
This publication is useful because it demonstrates that infrared radiation is beneficial in the treatment of photo-aged skin. This suggests that it can be safely and effectively used in clinical practice as a potential treatment strategy,
3	Actinic Keratosis	Quality Indicator	Type: Narrative Review
Schwartz RA Bridges TM Butani AK Ehrlich A. Actinic keratosis: an occupational and environmental disorder. [Review] [79 refs] [Journal Article. Review] Journal of the European Academy of Dermatology & Venereology. 22(5):606-15, 2008 May.
This publication is relevant because it provides a summary on all of the necessary information relating to actinic keratosis, including history, prevalence, detection methods and treatment strategies, It is useful to clinicians or researchers attempting to obtain information on actinic keratosis from one source.

Allergic contact dermatitis develops over time and requires penetration of the allergen through an impaired skin barrier to allow sensitization and re-exposure to generate the allergic reaction. Allergic contact dermatitis is usually a local reaction, manifested as itching, pain, redness, swelling, and wheals. Severe cases may be associated with more generalized symptoms. Symptoms usually begin within 12 hours of exposure, peak within 3–4 days, and subside within a week, once the allergen has been removed.

Predisposing factors include dermatoses, such as irritant contact dermatitis; skin trauma, including cuts, scratches, and abrasions from friction; environmental factors, such as dryness and sweating; and the nature, amount and concentration of the allergen. Leg ulcers are the most common diagnosis associated with allergic contact dermatitis.

Various products, such as cleansers, skin barriers, and protectants, may contain allergens, including perfumes, preservatives, and other chemicals used in product formulation. Other common allergens associated with allergic contact dermatitis include nickel, latex, hair dyes, chromates, and poison ivy and related plants.

Diagnosis and evaluation of allergic contact dermatitis include identification of the allergens. Location and distribution of the allergic reaction may assist in identification. Patch testing is confirmatory. Management is directed toward avoiding further exposure, protecting affected skin from additional trauma, and restoring skin integrity. Gentle cleansers, moisturizers and, possibly, anti-inflammatory medications may be useful.

In most cases, allergic contact dermatitis can be prevented by avoiding the use of products and treatments that contain potential allergens in patients with risk factors for barrier disruption.

Identify and Treat the Cause		Level of Evidence
1	Determine exposure to potential allergens in patients with suspected allergic contact dermatitis.	Not Assessed
2	Perform patch testing, if necessary, to confirm the diagnosis.	Level of Evidence Not Assessed
Address Patient-centered Concerns		Level of Evidence
3	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
4	Prevent the development of allergic contact dermatitis by maintaining skin integrity in patients with wounds, ostomies or incontinence by selecting hypoallergenic skincare and treatment products whenever possible.	Not Assessed
5	Prevent additional exposure to allergen.	Not Assessed
6	Treat affected skin to restore barrier function. Anti-inflammatory medications may be helpful.	Not Assessed
Provide Organizational Support		Level of Evidence
7	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Sensitization in atopic dermatitis	Quality Indicator	Type: Prospective Correlation study
Belhadjali H, Mohamed M, Youssef M, Mandhouj S, Chakroun M and Zili J. (2008). Contact sensitization in atopic dermatitis: results of a prospective study of 89 cases in Tunisia. Contact Dermatitis 58, 188-189.
In this prospective study, the frequency of contact sensitization was evaluated in the course of atopic dermatitis (AD) in a sample from the Tunisian population. Risk of sensitization was associated with duration of contact (p=0.017). Positive patch tests were associated with severe more often than moderate or mild AD, indicating the importance of removing the allergen.
2	Photoallergic contact dermatitis	Quality Indicator	Type: Retrospective Analysis
Devleeschouwer V, Roelandts R, Garmyn M and Goossens A. (2008). Allergic and photoallergic contact dermatitis from ketoprofen: results of (photo) patch testing and follow-up of 42 patients. Contact Dermatitis 58, 159-166.
In this study, photo contact allergic reaction to ketoprofen and other on steroidal antiinflammatory drugs, sunscreens and fragrance components, and the presence of prolonged photosensitivity related to it were investigated. Photoallegic contact dermatitis following ketoprofen is common. Frequently it presents much later and the dermatitis is persistent. Therefore, the patient my not mention ketoprofen in the history of ketoprofen-related (photo) allergic contact dermatitis.
3	Allergic contact dermatitis	Quality Indicator	Type: Cohort study (2 groups)
Kim JE, Park HJ, Cho BK and Lee JY. (2008). Influence of skin peeling procedure in allergic contact dermatitis. Contact Dermatitis 58, 142-146.
In this study, the frequency of positive patch test reactions for patients with a history of peeling was compared with a control group with no history of peeling. The peeling group had an odd ration of 1.957 (95% CI 1.048-3.653) for a positive patch test reaction compared with the control group (p

Protection of peristomal skin and maintenance of skin integrity plays a central role in ensuring a predictable pouch wear time with an intact seal. Compromised skin integrity may result in a worsening cycle of pouch leakage and skin erosion. Care of peristomal skin involves creating a dry surface, smoothing irregular contours and treating infection, while maintaining an adhesive seal.

Most ostomates require treatment for peristomal skin complications at some point. The following are risk factors for skin complications:

• A poorly sited or constructed stoma
• The presence of stoma complications, such as retraction, hernia or prolapse
• The presence of wound complications in or near the peristomal area
• Recurrent disease
• Obesity.

Skin complications may also occur due to lack of patient access to care by specialized ostomy nurses.

Prevention of peristomal skin complications begins preoperatively, with the selection of an appropriate site by a qualified stoma nurse, according to specific guidelines. The right site allows a secure pouch seal, simplifies self-care, and reduces the risk of stoma and skin complications. The surgical technique is also important, as an upward-pointing lumen and a minimum 2.5-cm protrusion of the stoma both reduce the risk of erosion of the barrier adhesive by effluent. Postoperatively, patient knowledge and use of meticulous skincare can keep the peristomal skin clean, dry and protected from injury from trauma and effluent. Maintenance of the integrity of peristomal skin relies on the following:

• The ostomate must know that peristomal skin should be normal in appearance and recognize changes. However, many patients believe that it is normal for the skin to be irritated. The most common peristomal skin complication is irritant contact dermatitis.
• The pouching system must be properly sized and contoured so that the skin at the base of the stoma is covered. Due to changes in the stoma and the abdomen over time, regular assessment of fit is necessary. Several pouch refittings may be necessary over the first few postoperative months, and additional refittings may be required over the patient’s lifetime.
• An appropriate pouch change schedule (usually every 4–7 days) must be established to prevent leakage. If leakage does occur, a clean system should be applied.
• Atraumatic adhesives, skin sealants for sensitive skin, and gentle cleansing can all protect peristomal skin from mechanical trauma. Using water or a pH-balanced cleanser and avoiding unnecessary use of skincare products reduces the risk of irritant contact dermatitis.
• Maintaining dry peristomal skin is critical both to obtain a good seal and to reduce the risk of candidiasis. After showering with the pouch on, the patient may use a hairdryer (cool setting) or allow the skin barrier and pouching system to air dry. On the day of a pouch change, if the pouch is removed before showering, the patient should pat the skin dry.
• The ostomate should be able to manage leakage using skin barrier powder, more frequent pouch changes and use of skin barriers to fill irregular surfaces. If these strategies do not correct the problem, a specialized ostomy nurse should be consulted.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Develop and implement a comprehensive perioperative education program for ostomates and incorporate frequent reinforcement.	Not Assessed
3	Implement a postoperative follow-up schedule that incorporates assessment of the stoma, peristomal skin, the pouching system, and patient self-care.	Not Assessed
Provide Local Care		Level of Evidence
4	Address problems with skin complications by reviewing appropriate self-care techniques, product and appliance selection and treating the complication.	Not Assessed
Provide Organizational Support		Level of Evidence
5	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
n/a

Normal intact skin forms a barrier that protects the body against pathogens, ultraviolet light, noxious substances, and fluid and electrolyte loss. The barrier function of the skin resides primarily in the stratum corneum, which is highly impermeable to water. This impermeability is due to the structure of the stratum corneum, which is composed of protein-rich nonviable cells and an intercellular lipid bilayer. Maintenance of barrier function depends on the stratum corneum having a 10% moisture content. Normally, loss or impairment of the skin’s barrier function accelerates homeostatic processes, including lipid synthesis and processing, to repair the barrier. The barrier function also adapts to the environment. Intercellular lipid content increases in a dry environment, reducing transepidermal water losses.

Numerous risk factors, however, can impair the skin’s barrier function, increase susceptibility to infection, and significantly affect health. • Inflammation alone can disrupt the skin barrier. • Dermatitis may be the cause or the result of an impaired skin barrier. • Hypersensitivity may develop when an impaired barrier allows entry of normally excluded chemicals and allergens. The importance of barrier disruption to the development of hypersensitivity is unknown. • Aging, which is associated with decreased skin thickness, barrier function and physiologic activity, predisposes elderly individuals to breaches of skin integrity. • Incontinence: Loss of skin integrity among institutionalized elderly individuals is frequently due to incontinence-related dermatitis. • Wounds: Wound exudate can damage normal skin surrounding the wound, and leaky dressings may result in peri-wound skin maceration. • Edema, due to lymphedema or venous insufficiency, stretches the dermis and epidermis, disrupting the skin barrier, causing inflammation and further skin damage, which may then result in infection. • Adhesive products, including tapes and bandages, such as hydrocolloids, films and some foams, and procedures to remove them, may compromise the skin’s barrier function. • Diabetes mellitus is associated with impaired skin barrier function, possibly due to reduced capillary circulation of the skin and abnormal lipid content of the stratum corneum. • Contact dermatitis may occur with skin barrier disruption and decreased skin hydration may increase sensitivity to irritants. • Xerosis may result from any condition that damages the skin barrier and increases transepidermal water loss. These conditions include dermatoses, frequent hand washing or exposure of skin to detergents or other damaging chemicals, and changes associated with ageing. • Stress: Chronic physiologic and psychological stress can reduce skin lipid production, delay normal barrier repair, and reduce the water content of the skin.

Clinical warning signs of an abnormal skin barrier include lack of skin elasticity, redness, inflammation, itching, scaling, cracking, and fissuring. Restoring and maintaining normal epidermal hydration is the most basic requirement for maintaining adequate skin barrier function. Useful measures include the selection of cleansers with a pH as close as possible to normal skin pH (5.4), possibly with added moisturizers, and routine skin moisturization, especially after bathing or contact with water.

The optimal treatment approach to maintain the skin’s barrier is individualized and based on specific risk factors, clinical signs, and underlying causes.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess each patient’s risk factors for skin barrier disruption.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Develop and implement an individualized plan to restore, maintain and/or prevent barrier impairment.	Not Assessed
4	Ensure the use of gentle cleansers and routine skin moisturizing.	Not Assessed
5	Protect skin from contact with urine or fecal material by using appropriate barriers, protectants and containment devices.	Not Assessed
6	Maintain wound moisture and bacterial balance and protect peri-wound skin.	Not Assessed
7	Reassess skin barrier function regularly and modify the clinical approach as necessary.	Not Assessed
Provide Organizational Support		Level of Evidence
8	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Topical skincare	Quality Indicator	Type: Systematic review
Hodgkinson B, Nay R, Wilson J (2007) A systematic review of topical skincare in aged care facilities. Journal of Clinical Nursing 16, 129-136.
This systematic review of systematic reviews, RCTs, and non-randomized controlled studies was conducted to determine the effectiveness of topical skincare interventions for residents of aged care facilities by examining the incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears, and by patient satisfaction. Since the interventions and outcomes measured in the studies varied, the results were not combined but one or more individual studies were reported. Although the results are inconclusive, evidence suggests the use of disposable rather than non-disposable bodyworns, no-rinse cleansers rather than soap, and bag bath to maintain skin integrity.
2	Skin Integrity	Quality Indicator	Type: Narrative Review
Sibbald RG, Campbell K, Coutts P, Queen D. Intact Skin – An Integrity not to be lost. Ostomy Wound Continence 2003;49(6):27-41
This comprehensive article outlines skin integrity issues and suggests products that might be used for prevention and treatment.
3	No-Sting Barrier Film	Quality Indicator	Type: Systematic review
Schuren J, Becker A, Sibbald RG. A liquid film-forming acrylate for peri-wound protection: a systematic review and meta-analysis (3M™ Cavilon™ no-sting barrier film) Int Wound Journal 2 (3) Sept 2005.
This publication is useful because it demonstrates the effectiveness of No-Sting Barrier Film in protecting peri-wound skin. The studies showed that the film protected the integrity of the skin, minimized pain and improved quality of life of patients.
4	No-Sting Barrier Film	Quality Indicator	Type: Narrative Review
Campbell K, Woodbury MG, Whittle H, Labate T, Hoskin A. Clinical evaluation of 3M no sting barrier film. Ostomy Wound Manage. 2000 Jan;46(1):24-30.
This publication is useful because it demonstrates the effectiveness of No-Sting Barrier Film in protecting peri-wound skin. The studies showed that the film protected the integrity of the skin, minimized pain and improved quality of life of patients.

Management of drainage, whether due to an exudative wound, stoma, enterocutaneous fistula, or incontinence, poses a similar challenge: effluent management, skin protection and odour control. Effluent management can be achieved through the use of fluid managers and collecting systems. Patient and family education and confidence with self-care routines is an integral part of effective management.

Wound Wound exudate provides a moist environment that is optimal for healing, but large amounts of exudate can damage peri-wound skin. Control of moderate to heavy wound exudate can be achieved through the use of absorbent dressings, such as alginate, hydro fibre, and foam dressings. If these provide inadequate exudate control, pouch techniques or a wound drainage collector may be required.

Stoma Many types of one- and two-piece pouch drainable or closed systems are available to manage stoma output. Accessories, such as convex inserts, belts and pouch covers, may increase pouch comfort and performance. Effective pouch function depends on the selection of the appropriate system, patient knowledge and ostomy care abilities, an intact seal and appropriate pouch wear times.

Urinary incontinence A variety of absorbent pads and undergarments are available for patients with urinary incontinence who remain incontinent despite specific treatment. These fluid management systems may also be appropriate for nocturnal use by patients who are effectively managed by prompted voiding during the day. External catheters may be used for male patients with intractable incontinence, and intermittent catheterization can manage urinary retention and overflow incontinence. Long-term indwelling catheters have been overused in nursing homes; these catheters significantly increase the risk of complications, especially urinary tract infection. As a result, their use should be restricted to specific indications and the principles of catheter care should be followed.

Fecal incontinence Several containment options exist for patients who still have fecal incontinence despite appropriate management, including dietary and lifestyle management, biofeedback, pharmacotherapy, and surgery. Disposable absorbent pads and undergarments can effectively absorb liquid feces. Other fluid management devices include anal bags, which consist of a drainable pouch attached to an adhesive wafer that fits around the anal opening, and various catheters or tubes attached to fecal collection bags.

Fistula The technique selected to manage drainage from an enteric fistula depends primarily on the discharge volume. Drainage from low-volume fistulas can usually be managed adequately using hydrocolloid, alginate, hydro fibre, or foam dressings, whereas drainage from high-volume fistulas can be managed with one- or two-piece ostomy systems (depending on the need for a window), a fecal incontinence collector, a customized pouching system, or a vacuum-assisted closure dressing.

Management of any odour is an important patient consideration. The primary approach to managing odour is to address the cause and, when possible, to control the fluids. Depending on the clinical problem, containment can be achieved using dressings and pouching or drainage devices. Appropriate use and securement of wafer barriers, pastes and adhesives can prevent leakage and odour. Topical metronidazole and secondary dressings containing charcoal may also be helpful.

Maintenance of skin integrity is important both for patient comfort and to prevent infection, wound extension and other skin complications. Selection of the right skin barriers and protectants and their correct use can restore and maintain skin integrity and prevent further skin damage.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history, assess the patient and analyze the drainage problem to determine the cause and how to treat it.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that the drainage problem has on a patient’s quality of life	Not Assessed
3	Contain drainage to maintain patient comfort and quality of life and prevent problems with odour and skin breakdown.	Not Assessed
4	Educate the patient and family on self-care techniques.	Not Assessed
Provide Local Care		Level of Evidence
5	Select appropriate drainage absorption or containment systems based on the amount and type of drainage.	Not Assessed
6	Consider absorbant products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
7	For patients with incontinence, inspect genital-perineal area daily to identify signs of contact dermatitis and skin breakdown.	Not Assessed
8	For patients with incontinence, prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	Not Assessed
Provide Organizational Support		Level of Evidence
9	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Incontinence management system trial	Quality Indicator	Type: Non-randomized controlled trial
Al-Samarrai NR. Uman GC. Al-Samarrai T. Alessi CA. Introducing a new incontinence management system for nursing home residents. Journal of the American Medical Directors Association. 8(4):253-61, 2007 May.
This article presents the results of a comparative study evaluating the introduction of the One Step Incontinence System (OSIS), an integrated incontinence product, in the Nursing Home setting (2 sites) by comparing it with the provision of a box of wipes at the bedside. It was found that cleansing was done more frequently using the OSIS system than the wipes.

Enterocutaneous fistulas (ECFs) may develop spontaneously, due to a variety of intestinal diseases, or postoperatively, due to complications. The first sign of an ECF is usually excess fluid leaking from an abdominal wound. Examination of the fluid can help to determine the origin of the tract. Concentrated digestive enzymes rapidly damage the skin around the fistula. ECFs can be classified according to output as low volume (500 mL/24 hours). High-volume fistulas are associated with high morbidity and mortality and decreased likelihood of spontaneous closure.

The management of enterocutaneous fistulas (ECFs) is based on addressing fluid and electrolyte balance and nutrition, preventing and controlling sepsis, containing effluent, maintaining periwound skin integrity, facilitating fistula closure, either spontaneously or surgically, and managing pain. Initial management focuses on managing sepsis, preventing hypovolemia, and decreasing intestinal output. This includes fluid resuscitation, NPO status, an H2-receptor antagonist and somatostatin. Imaging can determine the fistula anatomy, continuity of the bowel, presence of an abscess or obstruction, the likelihood of spontaneous closure and specific treatment needs. Spontaneous closure of enteric fistulas usually takes 1–2 months.

Holistic and interdisciplinary care is optimal for patients with a fistula. Appropriate management requires comprehensive assessment by an enterostomal therapist, expertise in product selection and use, and appropriate patient and family teaching to develop an effective individualized care plan. Effective fistula containment involves protection of perifistular skin, odour control, and measurement of effluent to determine electrolyte and nutritional supplementation requirements. Adequate nutritional support facilitates spontaneous closure, and a consultation with a dietitian may be beneficial. Effective containment is important to patient comfort, physical condition and psychosocial health. As fistula closure may take several months, inadequate control of odour and effluent can result in isolation, withdrawal, and depression. A social worker or psychologist may be of assistance in this regard.

Approaches to fistula management:

• Low-volume fistulas without odour problems can usually be managed simply, with dressings, such as hydrocolloid, alginate, hydro fibre, or foam dressings, and skin protectants.
• Low-volume fistulas associated with odour may require charcoal dressings and frequent dressing changes (with use of appropriate skin barriers and protectants), along with liquid and environmental deodorants and application of crushed metronidazole tablets. If this approach is ineffective, the high-volume fistula approach may be effective.
• High-volume fistulas can be managed with one- or two-piece ostomy systems (depending on the need for a window), a fecal incontinence collector, customized pouching system, vacuum-assisted closure dressing or catheter system in conjunction with appropriate skin barriers.

Many complex fistulas require surgical closure. The patient should be free of sepsis for at least 6–8 weeks and be in positive nitrogen balance before surgery. Surgical closure may occur between 10 weeks and 13 months after fistula development.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Focus initially on hemodynamic stabilization of patients with enterocutaneous fistulas and treatment of infection.	Not Assessed
4	Use appropriate imaging to determine fistula anatomy, treatment requirements, and likelihood of spontaneous closure.	Not Assessed
5	Perform a comprehensive patient and fistula assessment and develop a management plan addressing perifistular skin protection, odour control, and electrolyte and nutritional supplementation requirements.	Not Assessed
6	Manage fistulas using an interdisciplinary team and holistic approach, incorporating patient and family education.	Not Assessed
7	Reassess fistula closure regularly and modify the management plan as necessary.	Not Assessed
8	Use appropriate imaging to determine fistula anatomy, treatment requirements, and likelihood of spontaneous closure.	Not Assessed
Provide Organizational Support		Level of Evidence
9	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
n/a

Fecal or urinary incontinence and double incontinence, though common problems in the aging population, are not restricted to the elderly. The overall prevalence of these problems is unknown, but increasing prevalence is noted with age. Social discomfort among patients with incontinence is significant and can lead to fear of social contact, isolation, psychological distress among patients and caregivers, and unnecessary institutionalization. As a result, quality of the life is a key issue directing incontinence treatment.

Urinary incontinence is widespread in geriatric individuals and is estimated to affect 15% to 30% of those living in the community and 50% of nursing home residents. Women may be affected twice as often as men. The estimated cost of managing urinary incontinence in American nursing homes is more than $3 billion. The cause may be related to various causes, summarized in the acronym DIAPPERS: delirium, infection, atrophic vaginitis, psychological, pharmaceutical, endocrine (diabetes), restricted mobility, and stool impaction. Many causes of urinary incontinence are reversible, and thorough assessment is required for accurate diagnosis. Depending on the cause, treatment options include medical therapy with anticholinergic agents or hormones, biofeedback, and surgery.

Fecal incontinence is estimated to occur in 2% of the population, and prevalence may increase to 60% in the elderly, especially hospitalized patients and nursing home residents. Risk factors include female gender, multiparity, and advancing age. Some estimates indicate that fecal incontinence is more common in women than men. Intact pelvic floor muscles, neurologic integrity and normal sensation are critical to maintaining continence. Fecal incontinence is associated with diarrhea, constipation, fecal impaction, and laxative use; hyperosmotic enteral feeding; neurologic problems associated with stroke, diabetes, and multiple sclerosis; pelvic, neurologic, surgical and obstetric injury; drug side effects; and collagen vascular disease. Thorough assessment and diagnostic evaluation may identify the cause, type of incontinence, and appropriate treatment. Management may include the use of bulking agents, dietary management, biofeedback, and surgery for refractory cases. Bowel habit training may be useful in disabled patients and those with advanced dementia.

Double incontinence may be equally prevalent in men and women living in the community. As well, patients with spinal cord injury will generally experience both urinary and fecal incontence.

Incontinent dermatitis due to chemical irritation by urine and/or feces may lead to skin breakdown and local bacterial infection. Routine use of skin barriers and protectants, along with appropriate containment systems, can prevent and treat incontinent dermatitis.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history from the person identified to have urinary and/or fecal incontinence.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that urinary and fecal incontinence have on a patient’s quality of life.	Not Assessed
3	Provide information and advice on treatment options available in both primary and secondary care.	Not Assessed
Provide Local Care		Level of Evidence
4	Thoroughly assess patients with urinary incontinence, including a directed history, physical examination, laboratory testing, and urodynamic studies if appropriate.	Not Assessed
5	Thoroughly assess patients with fecal incontinence, including a directed history, physical examination, neurologic examination, and specialized investigations as appropriate.	Not Assessed
6	Determine and implement an appropriate treatment approach based on the cause and type of incontinence.	Not Assessed
7	Monitor incontinence treatment results and adjust the therapeutic approach as necessary.	Not Assessed
8	Recommend containment products and reassess their suitability. Consider absorbent products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
9	Ensure that skin integrity is restored and maintained in patients with incontinence through the use of skin barriers and protectants and appropriate containment devices.	Not Assessed
Provide Organizational Support		Level of Evidence
10	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Incontinence-associated dermatitis	Quality Indicator	Type: Systematic review
Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: A consensus. JWOCN 2007;34(1):45-54, quiz 55-6.
The purpose of this review was to examine incontinence-associated dermatitis (IAD) and strategies for assessing, preventing, and treating it. Very little evidence was found concerning IAD. More research is needed to evaluate the efficacy of various treatments for IAD.
2	Perineal dermatitis	Quality Indicator	Type: Retrospective Analysis
Bliss DZ, Savik K, Harms S, Fan Q, Wyman JF. Prevalence and correlates of perineal dermatitis in nursing home residents. Nursing Research 2006;55(4):243-51.
The prevalence of perineal dermatitis and factors affecting its incidence were evaluated in this study. 59,558 patient records were analyzed. The researchers found that 5.7% of the patients studied had perineal dermatitis. Perineal dermatitis was associated with impaired tissue tolerance, perineal problems such as incontinence (73% of patients with perineal dermatitis were incontinent), and altered toileting ability due to restraints.

Investigation of urinary and fecal incontinence may identify reversible or treatable conditions. Specific management strategies for patients with incontinence are determined by the type and cause of the problem.

Urinary incontinence is divided into urge, stress, overflow, functional, and mixed incontinence. Diagnosis entails a complete history, including a detailed voiding history, a physical examination, including a directed neurologic examination, plus selected investigations. Basic investigation includes urinalysis and culture, blood urea nitrogen, and creatinine. Additional investigations that may be required include urinary tract imaging, cytology, cystoscopy and urodynamics.

The initial management approach is to address potentially reversible factors, such as provision of assistance with toileting for immobile patients; identification and management of depression; treatment of urinary tract infection or fecal impaction; and altering medications or dosage schedules that may worsen incontinence, such as evening diuretic doses. Management strategies can be grouped into the following categories:

• Behavioural treatment: Urge and stress incontinence may respond to behavioural treatment, such as bladder training, pelvic floor muscle exercises, and biofeedback. These approaches may be helpful in the geriatric nursing home population. • Medical therapy includes anticholinergic agents for urge incontinence; topical and systemic estrogen in women with atrophic vaginitis and urethritis; and alpha-blocker therapy for benign prostatic hypertrophy. • Surgical treatment, such as bladder neck suspension and sling procedures, may be effective for stress incontinence in female patients. Artificial urinary sphincters may correct post-prostatectomy incontinence or neurologic sphincter deficiency. • Newer treatments: Sacral nerve root stimulation or injection of bulking agents around the sphincter may be attempted in patients who do not respond to medical therapy.

Fecal incontinence is complex and multifactorial. A complete history, physical examination, and functional and anatomic assessment of the anorectum, anal sphincters and pelvic floor are necessary for diagnosis and determination of appropriate treatment. For selected patients, anorectal manometry, anal endosonography, and pudendal nerve latency may be useful investigations.

Management strategies include the following: • Bowel training programs, including ensuring adequate fluid and fibre intake, using stool softeners appropriately, and providing regular toileting, can manage chronic constipation and prevent fecal impaction and incontinence. • Biofeedback may help with incontinence associated with neurologic disorders. • Surgery may be appropriate for patients with pelvic floor, anal canal, or anal sphincter damage. • Newer treatments: Nerve stimulation or injection of bulking agents in the sphincter may be useful for incontinence that does not respond to other treatments. • Colostomy may be an option for severe fecal incontinence that is not responsive to other interventions.

Identify and Treat the Cause		Level of Evidence
1	Take a thorough history and perform a complete physical examination for patients with incontinence. Perform additional investigations as indicated by initial findings.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life.	Not Assessed
3	Provide information and advice on treatment options available in both primary and secondary care.	Not Assessed
4	Use a validated quality of life and incontinence severity questionnaire.	Not Assessed
Provide Local Care		Level of Evidence
5	Develop and implement a treatment plan based on the type and cause of incontinence.	Not Assessed
6	Recommend containment products and reassess their suitability. Consider absorbent products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
7	Inspect genital-perineal area daily to identify signs of contact dermatitis and skin erosions.	Not Assessed
8	Develop individualized skin care plans for patients with incontinence and intact or irritated skin, based on regularly cleansing, moisturizing and protecting the perineal skin.	Not Assessed
9	Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	Not Assessed
10	Treat infected skin or other skin complications appropriately.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
n/a

Incontinence increases the risk of developing skin irritation, ulceration and infection, as does the use of incontinence containment products, such as diapers. The risk is further increased in patients who have received perineal radiation and in those with limited mobility. Specific risk factors for skin breakdown are the following:

• Moisture: Overhydration can result from incontinence and from pads or briefs that trap urine or liquid feces against the perineal skin, increasing perspiration. Skin barrier damage allows water and chemical absorption and bacterial overgrowth.
• Skin pH: Urine may be acidic or alkaline; and incontinence may upset the normal skin pH. Ammonia from urine and urea from both urine and overgrowth of fecal bacteria may increase skin pH above 8. Highly acidic urine may develop in people with poorly controlled diabetes.
• Microbial colonization: Prolonged perineal exposure to moisture due to incontinence allows bacterial overgrowth. Obesity, immune-compromise, diabetes and exposure of damaged skin to gastrointestinal flora and digestive enzymes all increase the risk of infection, which further damages the skin barrier. Candidiasis is the most common infection, but normal skin or gastrointestinal flora may also cause infection.
• Friction and shear: The movement of clothing, bedding, or incontinence containment devices against moist or wet skin causes friction that may erode the stratum corneum. Erosions, while generally superficial, may involve large perineal skin areas. Repositioning an immobile incontinent patient may produce shearing forces resulting in tissue injury.

It is important to inspect the perineal area for skin integrity and evidence of infection. In males, this includes inspecting the glans penis, retracting the foreskin (if present). In females, thorough assessment includes pulling back the labia majora and minora to allow inspection of the distal vaginal vault. Inspection of the anal area in all patients involves separating the buttocks and any skin folds, as these folds may be overlooked during cleansing and are likely to perspire, especially in the obese individual.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history to identify and address risk factors for skin breakdown in incontinent patients: moisture, increased skin pH, microbial colonization and friction and shear.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life.	Not Assessed
3	Provide information and advice on treatment options available in both primary and secondary care.	Not Assessed
4	Use a validated quality of life and incontinence severity questionnaire.	Not Assessed
Provide Local Care		Level of Evidence
5	Recommend containment products and reassess their suitability.	Not Assessed
6	Consider absorbent products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
7	Assess perineal skin carefully and regularly to identify signs of irritation, infection, contact dermatitis and skin excoriation.	Not Assessed
8	Develop individualized skin care plans for patients with incontinence and intact or irritated skin, based on regularly cleansing, moisturizing and protecting the perineal skin.	Not Assessed
9	Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	Not Assessed
10	Treat infected skin or other skin complications appropriately.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Incontinence and skin injury	Quality Indicator	Type: Prevalence study
Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. JWOCN 2007;34(3):260-9.
The purpose of this study was to analyze the prevalence of skin injury in areas exposed to incontinence. 19.7% of the 608 patients surveyed were incontinent of urine and 17.6% were incontinent of stool. The researchers found that fecal incontinence was associated with hypoalbuminemia, poor nutritional status, and a higher skin injury rate.
2	Perineal assessment tool	Quality Indicator	Type: Validation study
Nix DH. Validity and reliability of the perineal assessment tool. Ostomy Wound Management 2002;48(2):43-6, 48-9.
The purpose of this study was to evaluate the validity and reliability of the Perineal Assessment Tool. The Perineal Assessment Tool was designed to determine the risk of perineal skin injury in hospitalized patients by measuring four risk factors: duration of irritant, intensity and type of irritant, perineal skin condition, and contributing factors that may cause diarrhea. The scale was evaluated by comparing the scores assessed using the tool by wound, ostomy and continence nurses with the scores calculated by staff registered nurses and licensed practical nurses using the same tool. The researcher found that there was a very good correlation between the expert and staff nurses’ scores (r = 0.97, p < 0.0001), indicating that the Perineal Assessment Tool may be valid and reliable.

Skin care for people with incontinence is individualized, based on assessment and response to specific products. However, skin care is generally directed to the following goals:

• Prompt removal of soil and irritants from the skin
• Reduction or prevention of exposure to irritants and organisms
• Restoration or maintenance of skin barrier function.

The main strategies to achieve these goals are cleansing, moisturizing and protecting the skin.

• Cleansing: Routine hygiene includes cleansing the skin after each episode of incontinence and cleansing the entire perineal area daily. A cleanser containing water and a surfactant, with a pH close to normal skin pH is recommended. Moisturizers or moisture barriers may be incorporated into some skin cleansers.
• Moisturizing: Use of humectants and/or emollients after each cleansing replaces lost skin oils, promotes skin barrier function, softens skin, and soothes irritation.
• Protecting: Applying skin protectants and/or sealants whenever the skin is cleansed can block exposure of irritated skin both to drainage from eroded skin and to irritants in urine or feces. Routine use of protectants promotes restoration or maintenance of the normal skin barrier.

In cases of skin infection, local or systemic treatment is also indicated. Candidiasis is usually treated with an antimycotic cream that will also prevent exposure to moisture, whereas bacterial skin infection may require treatment with systemic antibiotics.

Routine skin care plus use of a containment device to minimize or prevent exposure of perineal skin to incontinence can reverse or prevent skin irritation from incontinence until a definitive continence management plan is developed and implemented.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history from the person identified to have urinary incontinence.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life.	Not Assessed
3	Provide information and advice on treatment options available in both primary and secondary care.	Not Assessed
4	Use a validated quality of life and incontinence severity questionnaire.	Not Assessed
Provide Local Care		Level of Evidence
5	Recommend containment products and reassess their suitability.	Not Assessed
6	Consider absorbent products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
7	Inspect genital-perineal area daily to identify signs of contact dermatitis and skin excoriation.	Not Assessed
8	Develop individualized skin care plans for patients with incontinence and intact or irritated skin, based on regularly cleansing, moisturizing and protecting the perineal skin.	Not Assessed
9	Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	Not Assessed
10	Treat infected skin or other skin complications appropriately.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Topical skin care	Quality Indicator	Type: Systematic review
Hodgkinson B, Nay R, Wilson J (2007) A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 16, 129-136.
This systematic review of systematic reviews, RCTs, and non-randomized controlled studies was conducted to determine the effectiveness of topical skin care interventions for residents of aged care facilities by examining the incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears, and by patient satisfaction. Since the interventions and outcomes measured in the studies varied, the results were not combined but one or more individual studies were reported.
2	Skin damage prevention	Quality Indicator	Type: RCT
Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: Economics of skin damage prevention. JWOCN 2007;34(2):143-52, discussion 152.
The clinical and cost effectiveness of different incontinence-associated dermatitis (IAD) prevention regimens for nursing home residents was evaluated in this study. Four regimens were analyzed: one regimen consisted of applying a polymer-based barrier film three times per week and the other three regimens consisted of applying various moisture barrier ointments or creams after each occurrence of incontinence. Nearly two thousand residents in sixteen nursing homes were evaluated, and it was determined that the barrier film regimen was effective at preventing IAD and was also associated with significantly lower costs than the three ointment regimens.

Skin contact with irritating chemicals causes acute inflammation, disrupts the natural skin barrier and causes irritant contact dermatitis. Inflammation is usually evident within a few hours and peaks within 24 hours. Brief contact with strong irritants may produce blisters whereas prolonged low-level exposure to milder irritants may cause redness and small lesions.

The irritant properties of a compound are associated with its chemical properties, amount and concentration of the compound, and the length and frequency of exposure. The region of the affected skin also plays a role, as skin thickness varies. Skin trauma, including cuts, abrasions and exposure to friction, may increase irritation. Environmental factors, such as heat and humidity, may also play a role.

Excreted bodily fluids are a common cause of irritant contact dermatitis, especially among patients with chronic wounds, ostomates, and incontinent individuals. Fecal material contains hundreds of organisms, many of which produce contact irritants. Wound exudate contains various enzymes that may damage normal periwound skin. Urinary incontinence is associated with elevated skin pH and barrier function impairment, which then allows skin breakdown and incontinent dermatitis to occur. When both urinary and fecal incontinence are present, the alkaline urine reactivates digestive enzymes, significantly increasing the risk of skin breakdown and bacterial infection. Many chemicals routinely used in the home and workplace are also associated with irritant contact dermatitis.

Management relies on protecting skin from further exposure using skin barriers and protectants, reducing inflammation and restoring skin integrity. Prevention relies on thoroughly assessing patients with risk factors for skin breakdown, developing and implementing an individualized skin care strategy, and reassessing and modifying the approach as necessary.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and determine exposure to irritating chemicals in patients with suspected irritant contact dermatitis.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Prevent development of irritant contact dermatitis by identifying and managing risk factors in incontinent patients, ostomates, and patients with chronic wounds.	Not Assessed
4	Prevent further exposure to irritant.	Not Assessed
5	Treat affected skin to reduce inflammation and restore barrier function	Not Assessed
Provide Organizational Support		Level of Evidence
6	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Irritant dermatitis	Quality Indicator	Type:
Wakashin K. Sanatary napkin contact dermatitis of the vulva: Location-dependent differences in skin surface conditions may play a role in negative patch test results. Journal of Dermatology 2007;34:834-837.
This recent case series describes six Japanese patients who developed irritant dermatitis when wearing sanitary napkins, but had negative results when a patch test was applied to the flexor side of their arms. The author makes the point that the wet conditions and friction caused irritant dermatitis of the genital skin that has thinner stratum corneum than the arm. This study may have implications for patients wearing protection for wet conditions created by incontinence.

An ostomy is a surgically created opening for removal of waste from various parts of the gastrointestinal tract or from the urinary tract. Patients with inflammatory bowel disease, bowel or urinary tract cancer, or abdominal or pelvic surgery may require an ostomy. The main ostomy types are colonostomy, ileostomy and urostomy. An ostomy may be temporary, to allow part of the intestine to heal, or permanent. Data on the number of patients with ostomies (ostomates) are difficult to gather, but estimates indicate than 500,000 to 800,000 Americans are currently living with an ostomy.

The ostomy is generally constructed on the abdominal wall at an individually selected site to allow optimum comfort, function and concealment. Postoperatively, recovery may be uneventful and the ostomy may function well for a long period of time. Complications may also occur, either soon after surgery or many years later.

Patient education begins even before the surgical procedure including, ostomy sitting, type of appliance, recommendations, and discussion of the implications of life with an ostomy. Postoperatively, education continues to develop patient confidence in day-to-day management, with outpatient support provided by specialized ostomy nurses. Generally, the more helpful the perioperative education, the better the adjustment.

In addition to learning how to manage their ostomy and care for the peristomal skin, ostomates face many psychological issues. Psychological adaptation may include dealing with issues with self esteem and body image, lack of confidence about self-care, social and sexual relationship concerns, and fears about returning to, or functioning in, the workplace. Support groups may assist ostomates to adjust.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options. Ostomate education should include training in ostomy management and care of the skin and support for psychological adjustment.	Not Assessed
Provide Local Care		Level of Evidence
3	Ensure that specialized ostomy nurses provide both pre- and postoperative education to ostomates.	Not Assessed
4	Provide regular follow-up and assessment to identify complications promptly and determine appropriate management.	Not Assessed
Provide Organizational Support		Level of Evidence
5	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
n/a

The prevalence of urinary, fecal and double incontinence increases with age. As a result, these disabling conditions are common in the elderly population living in the community and even more common among nursing home residents.

Urinary incontinence has significant psychological, social and quality-of-life impact. Incontinence often begins gradually and increases in frequency and severity to the point that affected individuals discontinue normal activities, adapting their behaviour to avoid embarrassment about urine leakage. Among the elderly, incontinence negatively affects morale of patients and their caregivers and causes social isolation and unnecessary institutionalization.

Fecal incontinence can have a devastating effect on quality of life, with substantial physical and psychological effects. It can lead to loss of independence and mobility, social isolation, and an altered sense of self.

• Physical: Incontinence causes wetness, odour, discomfort, and skin irritation.
• Psychological: Incontinence can damage self-esteem, due to feelings of shame and embarrassment. Depression and social isolation can result.
• Sexual: Incontinence can affect sexual relationships because of the fear of urine leakage during sexual activity.
• Quality of life: Incontinence affects quality of life at least as much as other chronic illnesses.

Feelings of shame about incontinence may prevent sufferers from discussing the problem with their physician. As a result, potentially reversible incontinence may never be identified, investigated, or treated appropriately.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history from the person with urinary incontinence; determine the type, reversibility, and appropriate treatment approaches.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Consider the potentially serious adverse effects that even mild urinary incontinence has on a patient’s quality of life and reassure them that many cases are treatable.	Not Assessed
3	Provide information and advice on treatment options available in both primary and secondary care	Not Assessed
4	Assess and address quality of life using a validated quality of life and incontinence severity questionnaire, e.g., • International Consultation on Incontinence Questionnaire (ICIQ) • Bristol Female Lower Urinary Tract Symptoms (BFLUTS) • Incontinence Quality of Life (I-QOL) • Stress and Urge Incontinence and Quality of Life Questionnaire (SUIQQ) • Urinary Incontinence Severity Score (UISS) • SEAPI-QMM • Incontinence Severity Index (ISI) • King’s Health Questionnaire (KHQ).	Not Assessed
Provide Local Care		Level of Evidence
5	Develop and implement an appropriate cause-specific treatment strategy and monitor treatment success.	Not Assessed
6	Implement appropriate strategies for fluid management and skin care.	Not Assessed
7	Recommend containment products and reassess their suitability.	Not Assessed
8	Consider absorbant products as: – a coping strategy pending definitive treatment – an adjunct to other ongoing therapy – long term management of urinary incontinence only after other treatment options have been explored	Not Assessed
9	Inspect genital-perineal area daily to identify signs of contact dermatitis and skin excoriation.	Not Assessed
10	Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing appropriate skin and barrier creams.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information	Not Assessed

Essential Publications
1	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Stothers L. Reliability, validity, and gender differences in the quality of life index of the SEAPI-QMM incontinence classification system. Neurourology and Urodynamics 2004;23(3):223–8.
2	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Avery K, Donovan J, Peters TJ, et al. ICIQ: A brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourology and Urodynamics 2004;23(4):322–30.
Evaluates symptoms and impact of urinary incontinenece.
3	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Jackson S, Donovan J, Brookes S, et al. The bristol female lower urinary tract symptoms questionnaire: Development and psychometric testing. British Journal of Urology 1996;77(6):805–12.
Bristol Female Lower Urinary Tract Symptoms (BFLUTS). Development and psychometric testing.
4	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Patrick DL, Martin ML, Bushnell DM, et al. Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL). Urology 1999;53(1):71–6.
Incontinence quality of life instrument: further development
5	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Kulseng-Hanssen S and Borstad E. The development of a questionnaire to measure the severity of symptoms and the quality of life before and after surgery for stress incontinence. BJOG: an International Journal of Obstetrics and Gynaecology 2003;110(11):983–8.
Stress and Urge Incontinence and Quality of Life Questionnaire (SUIQQ)
6	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Stach-Lempinen B, Kujansuu E, Laippala P, et al. Visual analogue scale, urinary incontinence severity score and 15 D – Psychometric testing of three different health-related quality-of-life instruments for urinary incontinent women. Scandinavian Journal of Urologyand Nephrology 2001;35(6):476–83.
Urinary Incontinence Severity Score (UISS): Psychometric testing of three different health-related quality-of-life instruments for urinary incontinent women.
7	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Kelleher CJ, Cardozo LD, Khullar V, et al. A new questionnaire to assess the quality of life of urinary incontinent women. British Journal of Obstetrics and Gynaecology 1997;104(12):1374–9.
King’s Health Questionnaire (KHQ): assess quality of life in urinary incontinent women.
8	Disease-specific quality of life measure	Quality Indicator	Type: Scale Description
Hanley J, Capewell A, Hagen S. Validity study of the severity index, a simple measure of urinary incontinence in women. British Medical Journal 2001;322(7294):1096–7.
Incontinence Severity Index (ISI): validity study

Living with an ostomy can have a significant effect on quality of life. The support and understanding of healthcare professionals, family and friends can increase adjustment and improve the quality of life for ostomates. Appropriate preoperative education can provide insight into the implications for everyday life of a stoma and help prepare the patient for the challenges of adjusting to this life change. Patient-centred concerns generally fall into the following categories:

• Concerns about surgery: Pre- and postoperatively, attitudes can range from regarding the surgery as a solution to a serious problem to seeing it as a devastating event.
• Psychological issues: The permanent and significant changes to bodily appearance and function as a result of stoma surgery can provoke feelings of loss and grief. Body image and self esteem may suffer.
• Concerns about ostomy care and skin care: These concerns can be addressed by reassuring the new ostomate that appropriate education will be provided and that he/she will develop the ability and confidence to manage self-care. Involving the patient in ostomy care as soon as possible helps the individual regain a feeling of control. Adjustment to life with an ostomy is improved by helpful preoperative education.
• Dealing with complications: Experiencing complications makes the process of adapting to life with a stoma more complex. Postoperatively, further education and practice in techniques with the assistance of a healthcare professional with expertise in managing a stoma can build patient confidence in their ability to manage the stoma.
• Managing stoma output: Stoma bags with gas filters may be important for ostomates who travel by air, as cabin pressure changes may significantly increase the passage of flatus. Medications may sometimes be necessary to modify bowel transit time. Ileostomy patients usually need to increase their water and salt intake to compensate for lack of absorption in the large bowel. Dietary changes and restrictions can help in managing stool consistency and reduce flatus, loose stools and odour. It is however, important for ostomates to eat a varied diet and to develop confidence about eating with friends and in restaurants as part of rehabilitation.
• Relationship concerns: Ostomates may be unsure of who to tell and how much to reveal. Participating in a support group can provide answers from others who have experienced and worked through the same dilemmas.
• Workplace issues: These issues include uncertainty about coping in the workplace and interacting with co-workers. Employability and insurability may also be concerns.
• Sexuality: Sexual partners of new ostomates may have anxieties about their partner, due to a lack of information. An open discussion with the partner is important to the couple’s adjustsment. For single people, it may often be difficult to know when to tell a potential sexual partner about the ostomy.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess each patient’s risk factors for skin barrier disruption.	Not Assessed
Address Patient-Centered Concerns		Level of Evidence
2	Provide appropriate preoperative education about the surgery and life changes involved in life with an ostomy for the patient and, if appropriate, for the family.	Not Assessed
3	Schedule routine follow-up visits to assess stoma and self-care techniques and to determine what additional support would be helpful.	Not Assessed
4	Provide the new ostomate with resources and support to facilitate adjustment.	Not Assessed
Provide Local Care		Level of Evidence
5	Develop and implement an individualized plan to restore, maintain and/or prevent barrier impairment.	Not Assessed
6	Ensure use of gentle cleansers and routine skin miniaturization	Not Assessed
7	Implement appropriate management of stoma drainage and draining fistulas with assistance from specialized clinicians.	Not Assessed
8	Provide postoperative education and training in self-management for new ostomates.	Not Assessed
9	Prevent delayed wound healing, infection, and wound enlargement by maintaining wound moisture and bacterial balance and protecting periwound skin.	Not Assessed
10	Reassess skin barrier function regularly and modify the clinical approach as necessary.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Enterostomal therapy nurses	Quality Indicator	Type: Retrospective Analysis
Harris C, Shannon R. An innovative enterostomal therapy nurse model of community wound care delivery: A retrospective cost-effectiveness analysis. JWOCN 2008;35(2):169-183.
The cost-effectiveness of enterostomal (ET) nurses in the treatment of both acute and chronic wounds in a community setting is analyzed in this retrospective study. The researchers found that ET nurses were associated with reduced costs. This was mainly due to faster wound healing times. The expertise of the ET nurses and their nursing care model was credited with reducing healing times. The researchers conclude that the involvement of ET nurses either directly or indirectly through the use of their nursing care model should lead to reduced costs and healing times.

Prevention and management of peristomal skin complications is an important element of ostomy care. The majority of ostomates require treatment for skin compromise at some point. Risk factors for skin complications include a poorly located or constructed stoma, obesity, wound complications in or near the peristomal area, and stoma complications, such as retraction, prolapse and hernia. Peristomal skin complications may be related to lack of access to qualified healthcare professionals with expertise in ostomy care. Many complications can be prevented with optimal pre-and postoperative education and care. Skin complications can be grouped into the following categories: Chemical injury:

• Irritant contact dermatitis may result from skin contact with stoma effluent or skin care products. In the area of contact, skin is erythematous, moist and painful. Shallow erosions may be present. Assessment may reveal a poorly fitting or leaking pouch, incorrect ostomy care techniques, or overuse of skin products.
• Pseudoverrucous lesions may develop with chronic skin exposure to effluent. The epidermis is thickened with white, grey, dark red or brown papules, which may be accompanied by pain or bleeding. Assessment may identify a poorly fitting pouching system and a history revealing lack of follow-up or pouch refitting.
• Encrustations are crystal deposits seen on skin exposed to alkaline, concentrated or infected urine. Pseudoverrucous lesions may also be present. Assessment reveals skin exposure to urine, which may be accompanied by an inadequate fluid intake, high urine pH, or history of kidney stones.

Mechanical injury:

• Pressure/shear results in erythematous or abraded skin in the area pressure is delivered. Assessment reveals erythema that does not resolve after removal of the pouching system. The skin barrier may not be seated comfortably or a tight ostomy or support belt may be used.
• Stripping can be seen as erythematous and denuded patches where an adhesive was used. The adhesive itself or improper adhesive removal techniques may be responsible. Assessment may determine whether the type of tape or technique is responsible. Leakage prompting frequent pouch changes may also be found.
• Mucocutaneous separation, or interruption in the suture line attaching the stoma to the skin, may be seen soon after surgery and result from surgical technique, excessive suture tension, poor healing and/or infection. Assessment should include verification of the integrity of the suture line or measurement of the extent of separation at each visit and a search for effluent at the base and walls of the wound to rule out a fistula.
• Mucosal transplantation results in mucosal tissue migrating from the base of the stoma or scattered near the stoma. This tissue may bleed when adhesive is removed. Transplantation results from seeding of mucosa onto the skin during stoma construction.

Infectious complications:

• Candidiasis initially presents as a pustule that progresses to burning and pruritic plaques with satellite lesions, due to overgrowth of Candida albicans. Assessment may reveal a history of antibiotic therapy, increased perspiration or recent episodes of leakage with increased moisture under the adhesive seal.
• Folliculitis appears as erythematous and possibly pustular lesions associated with hair follicles, due to infection with Staphylococcus aureus. Assessment may reveal frequent shaving or insufficiently gentle shaving technique.

Immunologic complications:

• Allergic contact dermatitis may appear as an erythemic and pruritic skin reaction located only on skin in contact with an allergen. Vesicles, papules or bullae may be seen, and the skin may be swollen, eroded or weeping. Sensitivity to chemicals or other ingredients in skin or ostomy care products, such as dyes, perfumes or adhesives, is usually responsible. A history of sensitivity reactions may be present.

Disease-related complications:

• Varices (caput medusae) appear as purplish skin with dilated and tortuous veins in patients with portal hypertension due to liver disease. Assessment may reveal a source of skin trauma and sites of bleeding or erosion.
• Pyoderma gangrenosum is a painful, possibly full-thickness and excavated ulceration with purplish edges. Approximately 50% of cases are related to underlying systemic diseases, such as inflammatory bowel disease, polyarthritis or hematologic disorders. Assessment and biopsy may reveal an underlying systemic disease.
• Malignancy usually appears as a brownish or gray friable growth on the stoma or peristomal skin, which may result from inadequate surgical resection, implantation during suturing, or recurrence. It is important to assess for pain, disease history and pouch leakage.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Ensure that appropriate strategies are in place to prevent the development of peristomal skin complications. These include pre- and postoperative patient education and regular follow up by a clinician with expertise in ostomy management.	Not Assessed
4	Assess peristomal skin at each follow-up visit to detect breaches of skin integrity and identify clinical features to determine potential etiology.	Not Assessed
5	Reassess skin barrier function regularly and modify the clinical approach as necessary.	Not Assessed
Provide Organizational Support		Level of Evidence
6	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information.	Not Assessed

Essential Publications
1	Peristomal complications	Quality Indicator	Type: Prospective Correlation study
Ratliff CR, Scarano KA, Donovan JM. Descriptive Study of Peristomal Complications J WOCN 2005;32(1):33-37.
In this prospective study, peristomal complications of patients with ostomies were assessed at 2-months post-op. Of the sample of 220 subjects, 13% developed complications, including mechanical damage, chemical damage and infection. The peristomal complication form that was developed from WOCN guidelines and used by the authors is provided in the article.
2	Stomal and peristomal complications	Quality Indicator	Type: Validation study
Colwell JC, Beitz J. Survey of wound, ostomy and continence (WOC) nurse clinicians on stomal and peristomal complications: A content validation study. JWOCN 2007;34(1):57-69.
The purpose of this study was to validate definitions of stomal and peristomal complications and their associated interventions. A survey was sent to expert wound, ostomy and continence nurses in the United States asking them to rate the definitions. The researchers found that the definitions were considered valid (mean score 3.64 on a scale of 1 to 4, SD = 0.30, content validity index = 0.91).

Management of peristomal skin complications depends on the type of complication and the cause.

Chemical injury:

• Irritant contact dermatitis may result from skin contact with stoma effluent or skin care products. One or more of the following may be required: a smaller opening for the pouching system or a refitting with a convex adhesive surface; filling of irregularities in the peristomal skin with a skin barrier product; or reinforcement of correct ostomy care techniques. Dusting irritated peristomal skin with hydrocolloid powder prepares it for forming a secure seal with the pouch adhesive.
• Pseudoverrucous lesions may develop with chronic exposure of the skin to effluent. The management approach is similar to that followed for irritant contact dermatitis. In addition, pouch changes may need to be more frequent during initial treatment.
• Encrustations are crystal deposits seen on skin exposed to alkaline, concentrated or infected urine. If pseudoverrucous lesions are present, they are managed as described above. White vinegar soaks can dissolve encrustations. The skin barrier can then be applied. It is important to ensure an adequate fluid intake to achieve a dilute urine and to check urine pH at each follow-up visit. If necessary, a 1-g maintenance dose of timed-release vitamin C can acidify the urine.

Mechanical injury:

• Pressure/shear results in erythematous or abraded skin in the area pressure is delivered. A smaller opening on the pouching device and/or a refitting maybe necessary. The belt should be loosened, or discontinued if possible.
• Stripping can be seen as erythematous and denuded patches where an adhesive was used. Skin sealants may decrease trauma during adhesive removal. It is also important to reinforce the importance of gentle adhesive removal techniques, in the direction of hair growth while providing support for the skin.
• Mucocutaneous separation, or interruption in the suture line attaching the stoma to the skin, may be seen soon after surgery. It may be necessary to irrigate the area and pack with a hydrocolloid or powder or absorbent materials for larger wounds. The pouching system is placed over the packing to cover the entire peristomal area.
• Mucosal transplantation results in mucosal tissue migrating from the base of the stoma or scattered near the stoma. Dusting the skin with hydrocolloid powder creates a dry environment and covers mucosal transplantation area before applying pouching system.

Infectious complications:

• Candidiasis initially presents as a pustule that progresses to burning and pruritic plaques with satellite lesions. Candidiasis is treated with antifungal powder at each pouch change until the infection has resolved. Patient education about drying the pouching system after exercise or contact with water can prevent further episodes. A skin sealant may improve pouching system adhesion in hot and humid weather.
• Folliculitis appears as erythematous and possibly pustular lesions associated with hair follicles, due to infection with Staphylococcus aureus. The ostomate should use a gentle shaving technique and avoid shaving more than once weekly. Using an antibacterial soap may also be helpful. Topical or systemic antibiotics may be necessary if local care does not clear the infection.

Immunologic complications:

• Allergic contact dermatitis appears as a skin reaction located only on skin in contact with an allergen. The cause should be identified and product use discontinued. Patch testing may be used. Antihistamine and/or corticosteroid treatment may be required.

Disease-related complications:

• Varices (caput medusae) appear as purplish skin with dilated and tortuous veins. Treatment is based on managing the underlying liver disease; selecting atraumatic products; and teaching gentle ostomy care techniques, management of minor bleeding and when to seek medical care.
• Pyoderma gangrenosum is a painful, possibly full-thickness and excavated ulceration with purplish edges. Treatment is based on management of the underlying systemic disease, absorption of local drainage, and use of topical anesthetics if necessary. A gentle pouch adhesive should be used, as wound drainage will increase the frequency of pouch changes.
• Malignancy usually appears as a brownish or gray friable growth on the stoma or peristomal skin. The pouching system should be refitted to provide a secure seal without covering the tumour. The patient’s physician should be consulted, as biopsy and resection are generally needed.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess each patient’s risk factors for skin barrier disruption.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Determine and implement appropriate management technique for the specific peristomal skin complication detected.	Not Assessed
4	Identify and implement appropriate strategies to prevent future complications, including patient education, reinforcement and follow-up.	Not Assessed
5	Reassess skin barrier function regularly and modify the clinical approach as necessary.	Not Assessed
Provide Organizational Support		Level of Evidence
6	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information	Not Assessed

Essential Publications
n/a

Skin barriers and protectants are an important component of routine skin care for patients with incontinence, chronic wounds, ostomies, and fistulas. Repetitive exposure of healthy skin to moisture, irritants and trauma from adhesive tape and appliances weakens the normal skin barrier, threatening skin integrity. Barriers and protectants can assist in both maintaining skin integrity and in treating periwound skin breakdown.

A skin barrier is defined as a permanent interface between two surfaces that protects the integrity of the skin, whereas a protectant is defined as an indirect temporary technique or application to maintain the integrity of skin at high risk of breakdown.

Skin barriers include the following products:

• Ostomy skin barrier systems: These systems create a secure protective barrier between the skin under the wafer barrier and the urine or fecal material discharged into the pouch. Wafer barriers are available in flat or convex styles, and they may be rigid or flexible. Some wafers have an adhesive backing and/or a tape perimeter. Barrier paste may be used to ‘caulk’ gaps and surface irregularities between the barrier and the skin. Barrier liquid, wipes, and powder protect the skin under the wafer and increase barrier adhesion.
• Ointments and creams: Disadvantages of these products include user variation in application techniques and amounts, potential allergen content, and the need for frequent reapplication.

o Zinc oxide preparations, although effective, easily available and inexpensive, have several disadvantages, including the chance of bacterial contamination; the stiff texture, which may interfere with topical treatments, clog containment devices and generate enough friction to damage skin when repeatedly removed and reapplied; and the inability of caregivers to see the skin. o Petrolatum-based ointments perform in a similar way to zinc oxide preparations, except that they may melt and wash off easily. o Silicone-based creams are more expensive than ointments and more resistant to wash off. They also generate less friction, and their transparency allows good skin visualization.

• Film-forming barriers (barrier films or skin sealants): These products differ considerably in composition and performance, but contain a protective polymer dissolved in a fast-drying carrier. Barrier films form a transparent, flexible, durable, moisture-repellant protective film that does not interfere with adhesive dressings or containment devices. They appear to have a low sensitization rate and are resistant to wash off.
• Adhesive dressings: Films and thin hydrocolloids serve both as dressings and skin barriers, when applied using a window-framing technique. These dressings do not require frequent changes and allow easy skin visualization. However, the dressing edge may lift and trap exudate or allow bacterial proliferation. Allergies are also possible.

Various types of skin protectants are available.

• Fluid managers: These comprise absorbent dressings and briefs and containment devices, such as ostomy pouch systems. Fluid managers remove effluent, including wound exudate, urine and fecal material, from the skin surface. Briefs, calcium alginates and hydrofibres bind fluid within their structure. Absorbent foams, which do not lock in fluids, may be associated with skin damage. The large variety of containment devices available allows product selection to be tailored to patient needs.
• Skin cleansers: These surfactant-based products remove debris from intact skin better than water or saline. However, they alter skin pH and dehydrate skin, and many cause sensitization. To avoid damaging the skin, these products should be used only when necessary and rarely on wounds.
• Moisturizers: Moisturizers are applied to intact skin to preserve skin barrier function and are best applied when the skin is damp, to trap moisture in the skin. Routine moisturizer use is essential to maintain skin integrity in patients with fragile aged skin. Hydrating agents, such as lactic acid or urea, bind moisture in the stratum corneum. Emollient creams contain lubricants, such as lanolin, which have high moisture retention properties. Many moisturizers contain allergens and chemical irritants, including stablizers, preservatives, emulsifiers, perfumes, and lanolins.

Identify and Treat the Cause		Level of Evidence
1	Take a careful history and assess skin integrity in patients with risk factors for skin breakdown, including age, skin damage, incontinence, and wounds.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Provide information and advice on prevention and treatment options.	Not Assessed
Provide Local Care		Level of Evidence
3	Develop and implement an individualized strategy to maintain skin integrity, manage risk factors, and treat wounds in patients with risk factors for skin breakdown. Ensure correct use of appropriate skin barriers and protectants.	Not Assessed
4	Reassess patients with an appropriate frequency, document progress, and refine strategy as necessary.	Not Assessed
5	Implement appropriate management of stoma drainage and draining fistulas with assistance from specialized clinicians.	Not Assessed
6	Protect skin in incontinent individuals from contact with urine or fecal material by using appropriate barriers, protectants and containment devices.	Not Assessed
7	Prevent delayed wound healing, infection, and wound enlargement by maintaining wound moisture and bacterial balance and protecting periwound skin.	Not Assessed
Provide Organizational Support		Level of Evidence
8	Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information	Not Assessed

Essential Publications
1	Topical skin care	Quality Indicator	Type: Systematic review
Hodgkinson B, Nay R, Wilson J (2007) A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 16, 129-136.
This systematic review of systematic reviews, RCTs, and non-randomized controlled studies was conducted to determine the effectiveness of topical skin care interventions for residents of aged care facilities by examining the incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears, and by patient satisfaction. Since the interventions and outcomes measured in the studies varied, the results were not combined but one or more individual studies were reported.

Skin tears are common preventable traumatic wounds more common in the elderly. Long term steroid use, chronic sun exposure and numerous age-related changes increase the fragility of the skin. Turning or lifting immobile patients, dressing changes, and bumping into furniture can all cause skin tears. Approximately half of all skin tears have no apparent cause. Although most skin tears occur on the limbs, tears on the back or buttocks may be mistaken for pressure ulcers.

The most important risk categories for skin tears are patients dependent on caregivers for total care; ambulatory patients, especially those with edema, purpura and ecchymosis; and patients with impaired vision.

The Payne-Martin Classification System for Skin Tears defines skin tears as traumatic wounds due to separation of epidermis from the dermis (partial-thickness wound) or of the epidermis and dermis from underlying structures (full-thickness wound). These wounds occur primarily on the extremities of older individuals and result from friction or friction plus shear. Skin tears are classified as follows:

• Category I: Linear and flap tears without tissue loss. In linear tears, the epidermis and dermis are pulled apart, with an appearance similar to an incision. In flap tears, the epidermis covers the dermis to within a millimetre of the wound edge.
• Category II: Tears with scant or moderate-to-large tissue loss. With a scant tissue loss tear, no more than 25% of the epidermal flap is lost. With a larger tear, more than 25% of the epidermal flap is lost.
• Category III: Tears with complete tissue loss. The entire epidermal flap is lost.

Preventing skin tears is a challenge for clinicians. Preventive strategies include assessing risk in individual patients, providing a safe environment with adequate lighting, ensuring that patients’ extremities are protected by clothing, padding bedrails and wheelchair arms, supporting patients’ arms and legs with blankets or pillows, using transfer techniques that prevent friction and shear, choosing nonadherent dressings, and using emollient soaps or gentle cleansers.

Appropriate management of skin tears includes gentle cleansing with saline; air drying; approximation of the skin flap; application of ointment, steri-strips or moist, nonadherent dressings secured by stockinette or gauze wrap; and regular assessment.

Identify and Treat the Cause		Level of Evidence
1	Assess elderly patients for risk of skin tears.	Not Assessed
Address Patient-centered Concerns		Level of Evidence
2	Educate the patient and family about the risk and prevention of friction and shear when handling patients.	Not Assessed
3	Provide a safe environment for elderly patients.	Not Assessed
Provide Local Care		Level of Evidence
4	Develop a protocol for prevention and management of skin tears	Not Assessed
5	Moisturize dry skin, especially arms and legs, twice daily.	Not Assessed
6	Maintain patient nutrition and hydration.	Not Assessed
7	Protect patients from self-injury and injury during routine care.	Not Assessed
8	Classify the skin tear using the Payne-Martin system.	Not Assessed
9	Assess the size of the skin tear regularly.	Not Assessed
10	Manage skin tears using atraumatic techniques for cleansing, protecting, and dressing wounds.	Not Assessed
Provide Organizational Support		Level of Evidence
11	Facilitate healthcare professionals to gain relevant knowledge and skills to provide appropriate prevention and management.	Not Assessed

Essential Publications
1	Skin tears classification	Quality Indicator	Type: Scale Description
Payne RL, Martin, M. Defining and classifying skin tears: need for a common language. Ostomy Wound Management. 39(5):16-20, 22-4, 26, 1993 Jun.
This article presents the classification system that is commonly used to describe skin tears.
2	Skin tears – at risk population	Quality Indicator	Type: Correlation study
McGough-Csarny, J. Kopac, C A Skin tears in institutionalized elderly: an epidemiological study. Ostomy Wound Management. 44(3A Suppl):14S-24S; discussion 25S, 1998 Mar.
This descriptive correlational study indicates the population at-risk for skin tears in long-term care facilities, suggesting that the following variables are associated with skin tears: stiffness and spasticity, sensory loss, limited mobility, poor appetite, use of multiple drugs and assistive devices, presence of bruising, and history of skin tears. Unfortunately, since multivariable analyses were not conducted, the relative contribution of each of these variables to the occurrence of skin tears is not known. Nevertheless, this information may be helpful for prevention programs being established by caregivers.
3	Tissue adhesives	Quality Indicator	Type: Systematic review
Farion KJ, Russell KF, Osmond MH, Hartling L, Klassen TP, Durec T, Vandermeer B. Tissue adhesives for traumatic lacerations in children and adults. CochraneDatabase of Systematic Reviews 2001, Issue 4. Art.No.:CD003326.DOI: 10.1002/14651858.CD003326.
This well-conducted systematic review of RCTs, undertaken in 2001 and updated in 2007 (2 studies added) to compare tissue adhesives (TAs) with standard wound closure (SWC) and TAs with other TAs in managing traumatic lacerations in children and adults. . No significant difference was found between TAs and SWC at any of the time points examined using the Cosmetic VAS (CVAS) or the Wound Evaluation Score (WES). When TAs were compared with TAs, no differences were found. Significant differences favouring TA were all pain scores results (parent, patient, physician, nurse) and time to complete the procedure (mins). Significant differences for complications: dehiscence favouring SWC, NNH 40, 95% CI 20 to 1168; and erythema favouring TA, NNH 10, 95% CI 5 to 239. From a cosmetic perspective, either TAs or SWC can be used for simple traumatic lacerations. TAs require less procedure time and produce less pain, but have an increased rate of dehiscence.
4	Tissue adhesives	Quality Indicator	Type: Systematic review
Farion KJ, Osmond MH, Hartling L, Russell KF. (2003). Tissue adhesives for traumatic lacerations: A systematic review of RCTs. Academic Emergency Medicine 2003;10(2):110-118.
This well-conducted systematic review provides a shorter report of the Cochrane review above (9 pages rather than 50). It was undertaken to compare tissue adhesives (TAs) with standard wound closure (SWC) and TAs with other TAs in managing traumatic lacerations in children and adults. No significant difference was found between TAs and SWC at any of the time points examined using the Cosmetic VAS (CVAS) or the Wound Evaluation Score (WES). When TAs were compared with TAs, no differences were found. Significant differences favouring TA were all pain scores results (parent, patient, physician, nurse) and time to complete the procedure (mins). Significant differences for complications: dehiscence favouring SWC RD 0.04, 95%CI 0.01 to 0.07, NNH 25, 95% CI 14 to 100; and erythema favouring TA RD -0.12, 95%CI -0.23 to -0.01, NNH 8, 95% CI 4 to 100. From a cosmetic perspective, either TAs or SWC can be used for simple traumatic lacerations. TAs require less procedure time and produce less pain, but have an increased rate of dehiscence.
5	Prevention and treatment of skin tears	Quality Indicator	Type: CPG (Clinical Practice Guideline)
LeBlanc K, Christensen D, Orsted HL, Keast DH. Best practice recommendations for the prevention and treatment of skin tears. Wound Care Canada 2008;6(1):14-30.
Recommendations for the management of skin tears are presented in this paper. The authors recommend managing skin tears by treating underlying causes, managing patient concerns, and following best practice guidelines for local wound care.